Golden Palms Rehabilitation And Retirement

The facility failed to document in Resident #1's medical record when Resident #1 was sent to the hospital on [DATE] for evaluation to right heel wound.

The facility failed to document the physician's order for evaluation to right heel wound.

These failures could place residents at risk for errors in care.

The findings Include:

Record review of Resident #1's face sheet dated 2/19/26 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bed confinement status and peripheral vascular disease (a condition involving narrowed, blocked, or spasmodic blood vessels, usually in the legs, which reduces blood flow).

Record review of Resident #1's MDS dated [DATE] revealed resident was at risk for developing a pressure ulcer.

Record review of Resident#1's Care Plan last reviewed on 01/28/26 revealed, Focus- has pressure ulcer, unstageable to heel-DTI.

Goal: pressure ulcer will show signs of healing and remain free from infection by/through review date.

Interventions: Notify nurse immediately of any new areas of skin breakdown.

During an interview on 02/19/26 at 7:20 PM, LVN A said that the LVN B informed her about Resident's #1 discoloration to her heel on 2/17/26, and that the doctor ordered for resident to be transferred to the emergency room for further evaluation. LVN A stated that she called the emergency room to give report to the emergency room nurse and that Resident #1 was transferred via ambulance. LVN A stated that she got busy with other residents and forgot to document that Resident #1 was transferred to the emergency room. LVN A stated that she knew documentation should have been done before shift ended.

During an interview on 02/20/26 at 10:35 AM, LVN B stated that she did wound care to Resident #1 on 2/17/26. LVN B stated that she assessed Resident #1's heel and noted that Resident #1's heel was purple but not open. LVN B stated that she called the nurse practitioner and she gave a new order, to send Resident#1 to the emergency room for further evaluation. LVN B stated that she told LVN A about the new order and continued with another resident. LVN B said that she did not document the change in condition because she was not Resident#1's nurse and told LVN A who was the charge nurse. In an interview on 02/20/26 at 6:00 PM, the DON said the expectation was that documentation in resident charts are to be timely and accurate.

She said nursing staff are expected to document change of conditions in real time but if unable to documentation should be completed prior to shift end.

Record review of the facility's policy, Documentation Cares Given undated revealed It is the policy of this facility to ensure cares are provided as delineated within the service plan.

Documentation of cares given is recorded by the care staff in the electronic record each shift Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE